2

Laser Fundamentals
DONALD J. COLUZZI, ROBERT A. CONVISSAR, AND DAVID M. ROSHKIND

The word laser is an acronym for light amplification by stim- Ordinary light, such as that produced by a table lamp,
ulated emission of radiation. In this chapter, brief descrip- usually is a warm, white color. “White” as seen by the
tions of these five terms, within the context of the unique human eye is really the sum of the many colors of the visible
qualities of a laser instrument, are presented as background spectrum: red, orange, yellow, green, blue, and violet. The
for a subsequent overview of the uses of lasers in dentistry. light usually is diffuse—that is, not focused. Laser light is
distinguished from ordinary light by two properties. Laser
Light light is monochromatic: It is generated as a beam of a single
color, which is invisible if its wavelength is outside of the
Light is a form of electromagnetic energy that exists as a visible part of the spectrum. In addition, the waves of laser
particle and that travels in waves at a constant velocity. The light are coherent, or identical in physical size and shape.
basic unit of this radiant energy is called a photon.1 The Thus the amplitude and frequency of all of the waves of
waves of photons travel at the speed of light and can be photons are identical. This coherence results in the produc-
defined by two basic properties: amplitude and wavelength tion of a specific form of focused electromagnetic energy.
(Figure 2-1). Amplitude is defined as the vertical height of The beams emitted from laser instruments are collimated
the wave from the zero axis to its peak as it moves around (produced with all waves parallel to each other) over a long
that axis. This correlates with the amount of intensity in distance, but once the laser beam enters certain delivery
the wave: The larger the amplitude, the greater the amount systems such as optical fibers or tips (e.g., in neodymium-
of potential work that could be performed. For a sound doped yttrium-aluminum-garnet [Nd:YAG], erbium, and
wave, amplitude correlates with loudness. For a wave emit- diode lasers), it diverges at the fiber tip. This monochro-
ting light, amplitude correlates with brightness. A joule (J) matic, coherent beam of light energy can be used to accom-
is a unit of energy; a useful quantity in laser dentistry is a plish the treatment objective.
millijoule (mJ), or one thousandth (10−3) of a joule (0.001 J). Using a household fixture as an example, a 100-watt (W)
The second property of a wave is wavelength (λ), the hori- lamp will produce a moderate amount of light for a room
zontal distance between any two corresponding points on area, with some heat. On the other hand, 2 W of laser light
the wave. This measurement is important to both how the can be used for precise excision of a fibroma while providing
laser light is delivered to the surgical site and how it reacts adequate hemostasis at the surgical site, without disturbing
with tissue. Wavelength is measured in meters (m). Dental the surrounding tissue.2 The difference between the 100 W
lasers have wavelengths on the order of much smaller units, of an ordinary light bulb able to light up a room and the
using terminology of either nanometer (nm), equal to one 2 W of a laser able to perform a surgical procedure lies in
billionth (10−9) of a meter, or micrometer (μm), one mil- the property of coherence. As an apt analogy, imagine a
lionth (10−6) of a meter (replaces the micron [μ] unit, still crew race on a river. The boat that comes in first is the boat
occasionally seen in laser science). in which all of the members of the crew team are working
As waves travel, they rise and fall about the zero axis a together. At any given moment, they are all at the same stage
certain number of times per second; this is called oscilla- of the stroke cycle, so that all of their energies are working
tion. The number of oscillations per unit time is defined together to propel the boat. All of the members of the crew
as frequency. Frequency is measured in hertz (Hz); 1 Hz team place their oars in the water at the same instant. They
equals one oscillation per second. Frequency is inversely all remove their oars from the water at the same instant.
proportional to wavelength: The shorter the wavelength, They are working together in perfect unison. In similar
the higher the frequency, and vice versa. Although the hertz fashion, all of the light waves in a laser work together in
as just defined is a basic unit in physics, it also is used more a beam of coherent energy. By contrast, in the boat that
specifically to describe the number of pulses per second of comes in last, the crew members may be seen to be at dif-
emitted laser energy. ferent stages of the stroke cycle. Some have their oars going

12
 CHAPTER 2  Laser Fundamentals 13

Wavelength

Amplitude

• Figure 2-1 Properties of electromagnetic waves. Amplitude is the

height of the wave from the zero axis to the peak. Wavelength is the
horizontal distance between two adjacent parts of a wave.

• Figure 2-2  An atom of an active medium in ground state.

into the water, and some have their oars coming out of the
water; some are at the top of the stroke cycle, and some are Orbit corresponding
to an excited level
at the bottom of the stroke cycle. The team members are
not working together as one. The work expended by this
disorganized crew, which cannot propel their boat forward
with any effective speed, would be analogous to the energy
from an ordinary light bulb, which is insufficient for exci-
sion of soft tissue.

Amplification
Amplification is the part of this process that occurs inside
the laser. In this section, the components of a laser instru-
ment are identified to show how laser light is produced.
The center of the laser is called the laser cavity. The fol-
lowing three components make up the laser cavity:
• Active medium
• Pumping mechanism • Figure 2-3  An atom of an active medium in excited state.
• Optical resonator
The active medium is composed of chemical elements, mol- Photon
ecules, or compounds. Lasers are generically named for the
material of the active medium, which can be (1) a container
of gas, such as a canister of carbon dioxide (CO2) gas in a
CO2 laser; (2) a solid crystal, such as that in an erbium-
doped YAG (Er:YAG) laser; (3) a solid-state semiconductor,
such as the semiconductors found in diode lasers; or (4) a
liquid, such as that used in some medical laser devices.
Surrounding this active medium is an excitation source,
such as a flash lamp strobe device, electrical circuit, electri-
cal coil, or similar source of energy that pumps energy into
the active medium. When this pumping mechanism drives
energy into the active medium, the electrons in the outer-
most shell of the active medium’s atoms absorb the energy.
These electrons have absorbed a specific amount of energy • Figure 2-4 An atom of an active medium spontaneously emits a
to reach the next shell farther from the nucleus, which is at photon and returns to a stable orbit, giving off the energy that it had
just absorbed, according to the principle of conservation of energy.
a higher energy level. A “population inversion” occurs when
more of the electrons from the active medium are in the
higher energy level shell farther from the nucleus than are in surfaces at each end. These mirrors or polished surfaces act
the ground state (Figure 2-2). The electrons in this excited as optical resonators, reflecting the waves back and forth,
state then return to their resting state and emit that energy and help to collimate and amplify the developing beam.
in a form known as a photon (Figure 2-3). This is called A cooling system, focusing lenses, and other controlling
spontaneous (not stimulated) emission (Figure 2-4). mechanisms complete the mechanical components. Figure
Completing the laser cavity are two mirrors, one at each 2-5 shows a schematic of a gas or solid active-medium laser
end of the optical cavity, placed parallel to each other; or (e.g., CO2, Nd:YAG). Figure 2-6 shows a schematic of a
in the case of a semiconductor diode laser, two polished semiconductor diode device.
14 CHA P T E R 2  Laser Fundamentals

Laser components, e.g., CO2 or Nd:YAG

Pumping mechanism:
flashlamp, electricity
Optical
cavity

Lens

Reflective Partially
mirror transmissive
mirror
Optical resonator
• Figure 2-5  A gas or solid active-medium laser, such as CO2 or Nd:YAG laser.

Semiconductor diode laser components

Pumping mechanism: electricity

Lens
Positive wafer

Negative wafer

Reflective Partially
surface transmissive
surface
Optical resonator
• Figure 2-6  Semiconductor diode device.

Stimulated Emission amplification of the light energy—thereby producing a laser

beam (Figure 2-8).
Stimulated emission is the process by which laser beams are
produced inside the laser cavity. The theory of stimulated Radiation
emission was postulated by Albert Einstein in 1916.3 He
based his work on some earlier work by physicists from The light waves produced by the laser are a specific form of
Germany (Max Planck) and Denmark (Niels Bohr), who electromagnetic energy.6 The electromagnetic spectrum is the
theorized a model of the atom as well as the quantum theory entire collection of wave energy, ranging from gamma rays,
of physics, which defined a quantum as the smallest unit of with wavelengths of 1 x 10−12 m, to radio waves, with wave-
energy emitted from an atom.4,5 Einstein, using this con- lengths of thousands of meters. All currently available dental
cept, further theorized that an additional quantum of energy laser devices have emission wavelengths of approximately 500
may be absorbed by the already-energized atom, resulting in to 10,600 nm, which places them in either the visible or the
a release of two quanta (Figure 2-7). This energy is emit- invisible (infrared) nonionizing portion of the electromag-
ted, or radiated, as identical photons, traveling as a coherent netic spectrum, as shown in Figure 2-9. Of note, the dividing
wave. These photons in turn are then able to energize more line between the ionizing, cellular DNA–mutagenic portion
atoms in a geometric progression, which further causes the of the spectrum and the nonionizing portion is at the junc-
emission of additional identical photons, resulting in an tion of ultraviolet and visible-violet light. Thus all current
 CHAPTER 2  Laser Fundamentals 15

dental lasers emit either a visible-light wavelength or an invis- The following four dental laser instruments emit visible
ible, infrared-light wavelength in the portion of the nonion- light:
izing spectrum called thermal radiation.7 The word radiation • Argon laser: blue wavelength of 488 nm
in this context does not imply radioactive or carcinogenic but • Argon laser: blue-green wavelength of 514 nm
simply means the emission of electromagnetic energy. • Frequency-doubled Nd:YAG laser, also called a potas-
sium titanyl phosphate (KTP) laser: green wavelength of
Incident photon 2 photons 532 nm
• Low-level lasers: red nonsurgical wavelengths of 600 to
635 nm (for photobiomodulation) and 655 nm (for caries
detection)
Argon lasers are no longer manufactured as dental surgi-
cal instruments, although they are still used for medical
procedures.
Other dental lasers emit invisible laser light in the near,
middle, and far infrared portion of the electromagnetic
spectrum. These include photobiomodulation devices with
wavelengths between 800 and 900 nm, as well as surgical
instruments, as follows:
• Diode lasers: various wavelengths between 800 and 1064
nm, using a semiconductor active medium of gallium
and arsenide, with the addition of either aluminum or
• Figure 2-7  An atom of an active medium showing stimulated emis- indium in some devices
sion, releasing two identical photons before returning to a stable state. • Nd:YAG laser: 1064 nm
• Erbium-chromium–doped yttrium-scandium-gallium-
1 Photon 2 Photons 4 Photons garnet (Er,Cr:YSGG) laser: 2780 nm
• Er:YAG laser: 2940 nm
• CO2 laser: 9300 nm and 10,600 nm

Laser Delivery Systems

Excited atom, Photon
Laser energy should be delivered to the surgical site by a
molecule, or ion method that is ergonomic and precise.8 Shorter-wavelength
• Figure 2-8  Light amplification by stimulated emission of radiation. instruments, such as KTP, diode, and Nd:Y-AG lasers, have

Currently available dental laser wavelengths on the electromagnetic spectrum

Invisible ionizing radiation Visible Invisible thermal radiation

400–700 nm 2000 nm 3000 nm

X-rays Ultraviolet Near infrared Mid-infrared Far infrared

KTP Nd:YAP Er,Cr:YSGG Er:YAG CO2 CO2

532 nm 1340 nm 2780 nm 2940 nm 9300 nm 10600 nm

Diagnodent, 655 nm
980 nm Nd:YAG
Visible LLLT
InGaAs Diode 1064 nm

810 nm AlGaAs Invisible LLLT 940 nm GaAlAs Diode laser

Diode 1064 nm InGaAsP Diode laser
• Figure 2-9  Part of electromagnetic spectrum showing division into ionizing, visible portion, and non-
ionizing portion.
16 CHA P T E R 2  Laser Fundamentals

small, flexible fiberoptic systems with bare glass fibers that All conventional dental instrumentation, either hand
deliver the laser energy to the target tissue (Figure 2-10). or rotary, must physically touch the tissue being treated,
Because the erbium and CO2 laser wavelengths are absorbed which gives the operator instant feedback. As mentioned,
by water, which is a major component of conventional glass dental lasers can be used either in contact or out of con-
fibers, these wavelengths cannot pass through these fibers. tact. The fiber tip can easily be inserted into a periodontal
Erbium and CO2 devices are therefore constructed with pocket to remove small amounts of granulomatous tissue
special fibers capable of transmitting the wavelengths, with or treat an aphthous ulcer (Figures 2-15 to 2-17). In non-
semiflexible hollow waveguides, or with articulated arms contact use, the beam is aimed at the target some distance
(Figure 2-11). Some of these systems employ small quartz away (Figure 2-18). This modality is useful for following
or sapphire tips that attach to the laser device for contact various tissue contours, but with the loss of tactile sensation,
with target tissue; others employ noncontact tips (Figure the surgeon must pay close attention to the tissue interac-
2-12). In addition, the erbium lasers incorporate a water tion with the laser energy. All of the invisible-light dental
spray for cooling hard tissues. Lasers may have different lasers—Nd:YAG, CO2, diode, and erbium—are equipped
fiber diameters, handpieces, and tips (Figure 2-13). Each with a separate aiming beam, which can be either a laser or
of these elements plays a significant role in the delivery of a conventional light. The aiming beam is delivered coaxially
energy (Figure 2-14). along the fiber or waveguide and shows the operator the
exact spot at which the laser energy will strike the tissue.

Spot Size
Lenses focus the active beam. With hollow-waveguide or
articulated-arm delivery systems, there is a precise spot
• Figure 2-10  An assembled fiberoptic delivery system consisting of
the bare fiber, a handpiece, and a disposable tip. at the point where the amount of energy is the greatest.

A B
• Figure 2-11 A, Articulated-arm delivery system, typical of CO2 lasers and some erbium devices.
B, Hollow waveguide delivery system of a CO2 laser.
 CHAPTER 2  Laser Fundamentals 17

• Figure 2-12  Typical erbium laser tip. • Figure 2-15 CO2 laser periodontal tip treating periodontal pocket.

• Figure 2-13  A variety of handpieces available with most CO2 laser • Figure 2-16  Nd:YAG laser fiber entering periodontal pocket.
systems offer a variety of spot sizes and focal distances.

• Figure 2-17  Nd:YAG laser fiber contacting aphthous ulcer.

• Figure 2-14  Fiber diameters for Nd:YAG and diode lasers, yielding
different spot sizes.

This focal point is used for incision and excision surgery. For
fiberoptic contact delivery systems, the focal point is at or
near the tip of the fiber, which again has the greatest amount
of energy. For CO2 lasers, which are used out of contact, the
focal point may be anywhere from 1 to 12 mm from the tis-
sue surface, depending on the handpiece being used (Figure
2-19). When the handpiece is moved away from the tissue
and away from the focal point, the beam is defocused (out
of focus) and becomes more divergent and therefore deliv-
ers less energy to the surgical site (Figure 2-20). At a small • Figure 2-18  Nd:YAG laser fiber out of contact treating aphthous ulcer.
18 CHA P T E R 2  Laser Fundamentals

ion
ion

tion

tter
iss
lect

orp

Sca
nsm
Ref

Abs
Relatively small

Tra
spot size on
tissue surface

• Figure 2-19  A handpiece at the correct distance from the tissue for
maximal effect is “in focus.”

• Figure 2-21  Four potential laser-tissue interactions.

microseconds (μsec) or milliseconds (msec). Peak powers

of approximately 10 to 50 times that of continuous-wave
power measurements are produced, and charring of the
tissue can be reduced. The more advanced units have
computer-controlled shutters that allow for these very
short pulses. Manufacturers have coined many terms to
Big spot size describe these short pulse durations, including “super
at tissue surface pulse” and “ultra speed.”
3. Free-running pulsed mode, sometimes referred to as
true pulsed mode. This emission is unique in that large
peak energies of laser light are emitted usually for micro-
By moving AWAY from
the tissue surface we can
seconds, followed by a relatively long time in which the
INCREASE the spot size laser is off. For example, with a free-running pulsed laser
with pulse duration of 100 μsec and pulses delivered at
• Figure 2-20 A handpiece moved away from the tissue is “out of
focus,” resulting in a larger spot size and less fluence. Out-of-focus 10 per second (10 Hz), the energy at the surgical site is
mode is excellent for hemostasis. present for 0.01% of a second and absent for the remain-
ing 99.99% of that second. Free-running pulsed devices
have a rapidly strobing flash lamp that pumps the active
divergent distance, the beam can cover a wider area, which medium. With each pulse, high peak powers in hun-
would be useful in achieving a wide yet shallow ablation dreds or thousands of watts are generated. Because the
of tissue or, at a more divergent distance, hemostasis. At a pulse duration is short, however, the average power that
greater distance, the beam will lose its effectiveness because the tissue incurs is small. Free-running pulsed devices
the energy will dissipate. cannot have a continuous-wave or gated-pulse output.
True pulsed lasers are driven by the action of the pump-
Emission Modes ing mechanism within the laser cavity. Gated-pulse lasers are
pulsed as a result of a shutter outside the laser cavity. Medi-
Dental laser devices can emit light energy in two modalities cal and scientific laser instruments are available with pulse
as a function of time: (1) constant on or (2) pulsed on and durations in the nanosecond (one billionth of a second),
off.8 The pulsed lasers can be further divided into gated and picosecond (one trillionth of a second), or smaller range.
free-running modes for delivering energy to the target tissue. These can generate tremendous peak powers, but the cal-
Thus three different emission modes are described, as follows: culated average pulse energies are small, allowing increased
1. Continuous-wave mode, in which the beam is emit- surgical precision. Some instruments can be controlled to
ted at only one power level for as long as the operator emit a single pulse.
depresses the foot switch.
2. Gated-pulse mode, characterized by periodic alter- Laser Effects on Tissue
nations of the laser energy, similar to a blinking light.
This mode is achieved by the opening and closing of a Depending on the optical properties of the tissue, the light
mechanical shutter in front of the beam path of a con- energy from a laser may have four different interactions with
tinuous-wave emission. All surgical devices that operate the target tissue (Figure 2-21), as follows9:
in continuous-wave mode have this gated-pulse fea- • Reflection
ture. Some instruments can produce pulses as short as • Absorption
 CHAPTER 2  Laser Fundamentals 19

CO2 and Nd:YAG

erbium and diode

• Figure 2-22  Diagram of the eye showing the effects of different wavelengths on various tissue types.
In general, CO2 and erbium lasers interact with the cornea and lens, whereas Nd:YAG and diode lasers
penetrate to the retina.

• Transmission correspondingly increased chances of interacting with the

• Scattering predominant chromophore of those wavelengths. Scattering
A good way to remember these four types of laser-tissue of the laser beam also could cause heat transfer to the tissue
interactions is with the mnemonic device RATS. adjacent to the surgical site, with the potential for injury
Reflection is simply the beam being redirected off the sur- from unwanted laser effects. However, a beam that is scat-
face, with no effect on the target tissue. The reflected light tered, or deflected in different directions, would be useful in
may maintain its collimation in a narrow beam, or it may facilitating laser curing of composite resin.
become more diffuse. As stated previously, the laser beam The following photobiologic effects are possible with use
generally becomes more divergent as the distance from the of a dental laser10:
handpiece increases. With some lasers, however, the beam • The principal laser-tissue interaction is photothermal, which
can still have adequate energy at distances greater than 3 m. means the laser energy is transformed into heat. The three
In any event, this reflection can be dangerous because the primary photothermal laser-tissue interactions are incision/
energy could be redirected to an unintentional target, such excision, ablation/vaporization, and hemostasis/coagulation.
as the eyes. This potential mistargeting is a major safety con- By varying the various laser parameters of beam diameter
cern in laser operation and the reason that every person in (called spot size), energy, and time, lasers can be made to
the dental treatment room must wear wavelength-specific perform any of the three photothermal interactions:
safety glasses with appropriate side shields. An example of 1. A laser beam in focus with a small spot size is used for
reflection would be the interaction between a CO2 laser and incision/excision procedures (Figure 2-23).
a patient’s titanium implants. CO2 laser energy reflected off 2. A laser beam with a wider spot size will interact with
the implants could be redirected to the dentist’s eyes. the tissue over a wider area, but more superficially,
The second interaction with tissue is absorption. Absorp- producing a surface ablation (Figure 2-24).
tion of the laser energy by the intended target tissue usually is 3. A laser beam out of focus will produce hemostasis/
the most desirable effect. The amount of energy absorbed by coagulation (Figure 2-25).
the tissue depends on that tissue’s characteristics, such as pig- • Photochemical effects occur when the laser is used to stim-
mentation and water content, and on the laser wavelength. ulate chemical reactions, such as the curing of composite
The primary and beneficial goal of laser energy is therefore resin by an argon laser. The breaking of chemical bonds,
absorption of the laser light by the intended biologic tissue. such as using photosensitive compounds exposed to laser
The third effect is transmission of the laser energy directly energy, can produce singlet oxygen radical for disinfec-
through the tissue, with no effect on the target tissue tion of periodontal pockets and endodontic canals.
(Figure 2-22). This effect also is highly dependent on the • Certain biologic pigments, when absorbing laser light
wavelength of laser light. Water, for example, is relatively of a specific wavelength, can fluoresce; this property can
“transparent” to (does not absorb) the diode and Nd:YAG be used for caries detection on occlusal surfaces of teeth.
wavelengths, whereas the water component of tissue fluids More information on the use of laser fluorescence for
readily absorbs erbium and CO2 wavelengths at the surface, caries detection may be found in the chapter on the use
so minimal energy is transmitted to adjacent tissues. The of lasers in operative dentistry.
diode and Nd:YAG wavelengths are transmitted through • A laser can be used in a nonsurgical mode for biostimula-
the sclera, lens, iris, cornea, vitreous humor, and aqueous tion for more rapid wound healing, pain relief, increased
humor of the eye before being absorbed on the retina. collagen growth, and a general antiinflammatory effect.
The fourth tissue interaction is scattering of the laser More information on this application can be found in
light, which weakens the intended energy. Scattering is Chapter 15, on low-level laser therapy (photobiomodu-
the predominant event with use of the near-infrared lasers lation) in dentistry.
in healthy soft tissue. Scattering causes the photons to • The pulse of laser energy on hard dentinal and osseous
change directions, leading to increased absorption, with tissues can produce a shock wave, which is an example of
20 CHA P T E R 2  Laser Fundamentals

A B C
• Figure 2-23  Laser excisional biopsy. A, Traction suture in place immediately preoperatively. B, Begin-
ning laser excision of lesion. C, Immediate postoperative view of excision site. Note the complete absence
of bleeding at the surgical site, one of the many advantages of laser surgery over conventional techniques.

very high percentage of water, excision/incision of soft tissue

commences at this temperature. At temperatures between
approximately 60° and 100° C, proteins begin to denature,
without any vaporization of the underlying tissue. This phe-
nomenon is useful in surgically removing diseased granulo-
matous tissue without affecting the healthy tissue, so long
as the tissue temperature can be controlled.12 At 70° to 80°
A C, soft tissue edges can be welded back together without
sutures.13
If the tissue temperature is raised to approximately 200°
C, the tissue becomes dehydrated and then starts to burn,
and carbon is the end product. Carbon is a strong absorber
of all wavelengths, so it can become a “heat sink” as the laser
procedure continues.14 The heat conduction will then cause
extensive collateral thermal trauma, referred to as tissue char-
ring. Tissue charring occurs when improper laser parameters
B are used.
• Figure 2-24  Laser ablation of excess tissue for treatment of cyclo- For dental hard tissue, the primary interaction occurs at
sporine-induced gingival hyperplasia. The patient was an adolescent 100° C, when the water within the hydroxyapetite crystal
kidney transplant recipient. A, Immediate preoperative view. B, One- is converted to steam, whose increased volume causes an
week postoperative view of laser-ablated area. explosive expansion and removal of that tissue.15
Laser emission modes play an important role in increas-
ing the tissue temperature. The important principle of any
the photoacoustic effect of laser light. This process often is laser emission mode is that the light energy strikes the tissue
called spallation. for a certain length of time, producing a thermal interac-
More information on spallation is presented in Chapter tion.16 If the laser is used in a pulsed mode, the targeted
10, on operative dentistry. As discussed next, the main tissue may have time to cool before the next pulse of laser
photothermal effect of dental lasers is tissue water vapor- energy is emitted. In continuous-wave mode, the opera-
ization; accordingly, the primary treatment goal is surgical, tor must cease the laser emission manually so that thermal
that is, the removal of tissue, as opposed to fluorescence or relaxation of the tissue may occur. Thin or fragile soft tissue,
biostimulation. for example, should be treated in a pulsed mode so that the
amount and rate of tissue removal are slower, but the chance
Tissue Temperature of irreversible thermal damage to the target tissue and the
adjacent nontarget tissue is minimal. Longer intervals
The thermal effect of laser energy on tissue primarily between pulses also can help avoid the transfer of heat to
involves the water content of tissue and change in the tem- the surrounding tissue. In addition, a gentle air stream or an
perature of the tissue. As Table 2-1 shows, when target tis- air current from the high-volume suction will aid in keep-
sue containing water is heated to a temperature of 100° C, ing the area cooler. Similarly, with use of hard tissue lasers, a
vaporization of the water within the tissue occurs; this pro- water spray will help prevent microfracturing of the crystal-
cess is called ablation.11 Because soft tissue is composed of a line structures and reduce the possibility of carbonization.
 CHAPTER 2  Laser Fundamentals 21

A B C
• Figure 2-25  Laser coagulation of an aphthous ulcer on the floor of the mouth. A, Preoperative view.
B, Applying laser energy to lesion. C, Immediate postoperative view of surgical site.

TABLE
2-1 Temperature Effects on Oral Soft Tissue
Short pulse
Tissue
Temperature (° C) Observed Effect(s)
37 C normal body temperature Energy

>60 C Coagulation and protein denatur-

ation
100 C Vaporization of intra- and extra-
cellular water
(J) Time

Longer pulse
Conversely, thick, dense, fibrous tissue requires more energy
for removal. For the same reason, dental enamel, with its
Energy
higher mineral content, requires more ablation power than
softer, more aqueous carious tissue. In either case, if too
much thermal energy is used, healing can be delayed, and
postoperative discomfort may be greater than normal.
Lasers have wide-ranging variability in pulse parameters
(Figure 2-26). To allow tissue cooling, some lasers permit (J) Time
the surgeon to change the amount of “on” time of the pulse,
called the pulse width. Other lasers allow the surgeon to con- Much longer pulse
trol the amount of “off” time between pulses. By varying
the amount of time the laser pulses on and off, the surgeon
is better able to treat different tissue types. The laser buyer Energy
should evaluate the amount of variability built into the unit.
Some units have fixed pulse widths that cannot be changed.
This limitation curtails the surgeon’s ability to modify set-
tings for optimal treatment of different tissues.
Duty cycle, also called emission cycle, is the term used to (J) Time
describe the amount of on and off time. A duty cycle of 10% • Figure 2-26  Various pulse parameters.
means that the laser is on for 10% and off for 90% of the
time. A duty cycle of 50% means that the laser is on for half
the time and off for half. Thin, friable tissues should be treated pigment, blood constituents, and minerals (Figure 2-27).
with small duty cycles, whereas thicker tissue may be treated Laser energy can therefore be reflected, absorbed, trans-
with larger duty cycles or with continuous-wave emission. mitted, or scattered, depending on the composition of the
target tissue. The primary absorbers of specific laser energy
Absorption of Laser Energy by Dental Tissues are called chromophores.7,17 Water, which is present in all
biologic tissue, maximally absorbs the two erbium wave-
Different laser wavelengths have different absorption coef- lengths, followed by the two CO2 wavelengths. Conversely,
ficients, with the primary oral tissue components of water, water allows the transmission of the shorter-wavelength
22 CHA P T E R 2  Laser Fundamentals

Approximate net absorption curves of various tissue components

Wavelength (nm)
100 1000 10,000

105 Hb

Absorption coefficient (1/cm)

104 Melanin
103
102 Tooth
enamel
101
1
101 H 2O
102
103
104
KTP Diodes Nd:YAG Nd:YAPEr,Cr:YSGG Er:YAG CO2
532 810 980 1064 1340 2780 2940 lasers

• Figure 2-27  Approximate absorption curves of the prime oral chromophores.

lasers (e.g., diode, Nd:YAG). Tooth enamel is composed A small extinction length means that the laser energy is maxi-
of carbonated hydroxyapatite and water. The apatite crystal mally absorbed by that tissue with no deep penetration and
readily absorbs the CO2 wavelength and interacts to a lesser thus minimal possibility of deep thermal damage. A large
degree with the erbium wavelengths. It does not interact extinction length means that the laser energy penetrates deep
with the shorter wavelengths. Hemoglobin and other blood into that tissue. Because CO2 and erbium lasers are the two
components and pigments such as melanin absorb diode wavelengths best absorbed by tissue with high water con-
and Nd:YAG laser wavelengths in variable amounts. tent, these wavelengths have the smallest extinction length
Human dental tissues are composed of a combination of in mucosa and are least likely to cause deep thermal dam-
compounds, so the clinician must choose the best laser for age, so long as proper operating parameters are used. The
each treatment.18 For soft tissue treatments, the practitio- extinction length for CO2 lasers in mucosa, for example, is
ner can use any available wavelength, because all dental laser 0.03 mm. Lasers with greater extinction lengths in mucosa,
wavelengths are absorbed by one or more of the soft tissue such as Nd:YAG (1 to 3 mm) and diode lasers, are safe to
components. For hard tissue, however, the erbium lasers and use provided that correct operating parameters are followed.
the 9.3-μm CO2 laser with very short pulse durations easily Conversely, the use of these wavelengths by operators with-
ablate layers of calcified tissue with minimal thermal effects. out adequate training carries the risk of thermal damage to
Of interest, the short-wavelength lasers (e.g., diode, Nd:YAG) the underlying tissue.
are essentially nonreactive with healthy tooth enamel. Recon-
touring gingival tissue close to a tooth can therefore proceed Laser-Tissue Summary
uneventfully with use of these wavelengths. Conversely, if soft
tissue is impinging into a carious lesion, an erbium laser can To determine the tissue interactions associated with a
remove the lesion and the soft tissue very efficiently, so long as particular laser device, the following factors must be
appropriate settings are used for each tissue type. considered20:
In addition to unique absorptive optical properties, all 1. Each laser wavelength will affect the interrelated com-
wavelengths have different penetration depths through tis- ponents of the target tissue: water content, color of the
sue. The erbium and CO2 laser wavelengths are so well tissue, vascularity, and chemical composition.
absorbed by tissue with a high water content (e.g., mucosa) 2. The diameter of the laser spot on the tissue, or spot size,
that they penetrate only a few to several μm deep into the whether delivered in contact or noncontact with the tis-
target tissue, whereas diode and Nd:YAG lasers can reach a sue, will create a certain amount of energy per square
few millimeters deeper. It is important to recognize that in millimeter of tissue. This is called energy density, or flu-
keeping with the differences in penetration of the various ence. An inverse relationship exists between spot size and
wavelengths into mucosa, tissue interaction may continue fluence; the smaller the spot size, the greater the fluence
at levels beyond the desired depth of the surgical field. This (Figure 2-28). For example, a beam diameter of 200 μm,
increased penetration could lead to deep thermal necrosis of compared with a beam diameter of 300 μm at the same
underlying tissue and osteonecrosis of bone. output setting, will have more than twice as much energy
Extinction length is defined as the thickness of a substance density. Use of the smaller spot size thus will result in
in which 98% of the energy from the laser is absorbed.19 greatly increased thermal transfer from the laser to the
 CHAPTER 2  Laser Fundamentals 23

Deep effect on tissue Superficial effect on tissue

Small spot size Large spot size

5W Same power 5W

Narrow, deep effect Wide, shallow effect

(think incision) (think ablation)
• Figure 2-28  Graphic representation of the relationship between spot size and fluence. The same wave-
length and power were used but the spot size was changed. On the left, the incision is narrow and deep
with a smaller spot size; on the right, the incision is wide and shallow with a larger spot size.

temperature rise. Accordingly, two specific aspects of

laser operation need to be addressed:
a.  Repetition rate of the pulsed-laser emission mode: the
number of pulses per second. The repetition rate is
measured in Hz.
b.  Hand speed: the speed of moving the laser through
the tissue. A rapid movement of the laser through the
surgical field may not permit adequate absorption of
the energy by the tissue. Conversely, moving the laser
through the surgical field too slowly may result in too
much thermal damage to the tissue (Figure 2-29).
• Figure 2-29  Effect of hand speed on incisions. Both incisions were 4. Using a water or air spray also can cool the tissue, which
made with the same handpiece and spot size. The incision on the left would affect the rate of vaporization.
was performed with a very slow hand speed, whereas the incision on
The laser practitioner must be aware of these factors before
the right was performed with a faster hand speed.
beginning treatment. Selection of the appropriate wave-
length, beam diameter (spot size), focused or defocused
distance, Hz setting, and amount and type of tissue cool-
tissue, with a corresponding increase in absorption of ing can then be achieved. The correct combination of all of
heat in that smaller area. If the beam has divergence, these parameters should ensure an efficient procedure and
moving it away from the tissue will increase its diameter, a beneficial outcome. Laser training is critically important
thereby lessening the energy density. in determining how to manipulate these parameters, as dis-
3. The amount of time during which the beam is allowed cussed in more detail in Chapter 16, on practice manage-
to strike the target tissue will affect the rate of tissue ment considerations in laser dentistry.
24 CHA P T E R 2  Laser Fundamentals

Laser Safety (IEC), headquartered in Geneva, Switzerland, promulgates

General Principles similar standards and regulations.
At present, approximately two dozen indications for use
All laser devices come with complete instructions on the of specific dental lasers are recognized. All wavelengths and
safe use of the machine. Every laser practitioner should devices of adequate power may be used for every aspect of
know certain fundamentals, but the primary responsibility intraoral soft tissue surgery. The erbium lasers may be used
for safe and effective operation of the laser is assigned to the for carious lesion removal, tooth preparation, endodontic,
laser safety officer for the clinical facility.21,22 This person and osseous procedures. The 9300-nm CO2 laser also may be
provides all necessary information, inspects and maintains used for some hard tissue procedures, with the possibility of
the laser and its accessories, and ensures that all safety proce- more indications pending regulatory clearance. Some instru-
dures are implemented. More information on the role of the ments have specific clearances for procedures such as sulcular
laser safety officer may be found in Chapter 16. debridement and tooth whitening. The dental practitioner
The patient and all members of the surgical team must may use the laser for procedures other than for the cleared
wear appropriate protective eyewear when the laser is oper- indications because the FDA does not regulate dental practice;
ating, to prevent damage from any reflected or accidental however, using a laser for a non–FDA-cleared procedure may
direct energy exposure. The surgical environment must have have legal ramifications in the event of a malpractice claim.
a warning sign posted, with limited access to the treatment Hospitals and institutions have their own credential-
room. High-volume suction must be used to evacuate the ing programs for the use of lasers in their facilities, and a
plume formed by tissue ablation, and the normal infection published curriculum guideline has established standards of
protocol must be followed. The laser itself must be in good dental laser education. The scope of practice—as defined by
working order so that the manufacturer safeguards prevent the dental practice act of each state or other jurisdiction—
accidental laser exposure. Masks must be of appropriate fil- and the training and clinical experience of the dental laser
tering capacity to prevent inhalation of laser plume. Most operator are the primary factors that should determine how
laser procedures should be performed with the surgeon the device is used.
wearing a 0.1-μm filtration mask. Regular cup-shaped den-
tal masks are insufficient for filtering the laser plume and Benefits and Drawbacks of Dental Lasers
should not be worn during laser surgery. Laser plume results
from the aerosol byproducts of laser-tissue interaction, One of the main benefits of using dental lasers is the capa-
which may contain particulate organic and inorganic matter bility of selective and precise interaction with diseased tis-
(e.g., viruses, toxic gases, chemicals) and may be infectious sues. Lasers also allow the clinician to reduce the amount
and/or carcinogenic. of bacteria and other pathogens in the surgical field and,
in the case of soft tissue procedures, achieve good hemo-
Laser Regulatory Agencies stasis with reduced need for sutures.24-27 Many researchers
have shown that the ability of lasers to seal blood ves-
In most countries, regulatory agencies control both the sels and lymphatic channels results in reduced postop-
laser operator and the laser manufacturer, and standards are erative edema, which in turn results in less postoperative
strictly enforced. discomfort.28
In the United States, the American National Standards The hard tissue laser devices can selectively remove dis-
Institute (ANSI) provides guidance for the safe use of eased tooth structure because a carious lesion has much
laser systems by specifically defining control measures for higher water content than healthy tissue, and water is the
lasers.23 The Occupational Safety and Health Administra- primary absorber of that wavelength of laser energy.15,29-31
tion (OSHA) is primarily concerned with a safe workplace These same devices confer advantages over conventional
environment, and numerous requirements exist for laser high-speed handpieces as they interact with the tooth sur-
protocols. The Center for Devices and Radiological Health face; for example, laser-treated dentin has no “smear layer,”
(CDRH) is the bureau within the Food and Drug Admin- and the cavity preparation has been disinfected because of
istration (FDA) whose purpose is to standardize the manu- the bactericidal nature of laser energy.32
facture of laser products and to enforce compliance with the The disadvantages of the current dental laser instruments
medical devices legislation.22 All laser manufacturers must are the relatively high cost and the required training.33 Most
obtain permission from the CDRH to make and distribute dental instruments are both side-cutting and end-cutting,
each device for a specific purpose; this marketing clearance so a modification of clinical technique is required in using
means that the FDA is satisfied that the laser is both safe lasers, which are almost exclusively end-cutting. The clinician
and effective to operate for that purpose. The owner’s man- must prevent overheating of the tissue and guard against air
ual for the particular laser model instructs the operator on embolism caused by excessive pressure of air and water spray
how to use the device for the particular CDRH-regulated during laser procedures. Another drawback of erbium lasers
procedure. is the inability to remove metallic restorations. In addition,
In countries and jurisdictions outside of the United despite laser manufacturers’ claims to the contrary, no single
States, the International Electrotechnical Commission wavelength will optimally treat all dental disease.34
 CHAPTER 2  Laser Fundamentals 25

Thus proper laser training is critical in deciding which 5. Bohr N: The theory of spectra and atomic constitution, ed 2,
wavelength to use and which model to purchase.35 Some Cambridge, Mass, 1922, Cambridge University Press.
manufacturers provide excellent hands-on training both at 6.  The Columbia electronic encyclopedia, New York, 2003, Colum-
seminars and in the office, whereas others give the buyer bia University Press. Available at http://www.encyclopedia.com
Accessed July 30, 2008.
nothing more than a CD and training manual. This issue is
7. Manni JG: Dental applications of advanced lasers, Burlington,
discussed in more detail in Chapter 16. Mass, 2004, JGM Associates.
8. Coluzzi DJ, Convissar RA: Atlas of laser applications in dentistry,
Lasers in Dentistry: Now and in the Future Hanover Park, Ill, 2007. Quintessence.
9. Miserendino LJ, Levy G, Miserendino CA: Laser interaction with
As mentioned, all dental surgical lasers currently available biologic tissues. In Miserendino LJ, Pick RM, editors: Lasers in
are designed for soft tissue procedures; only the two erbium dentistry, Chicago, 1995, Quintessence.
and the 9.3-μm CO2 wavelengths are safe and effective for 10. Niemz MH: Laser-tissue interaction: fundamentals and applica-
use with teeth and bone. Therapeutic, or photobiomodu- tions, ed 3, (enlarged) Berlin, 2007, Springer.
lation, lasers show beneficial results for healing, although 11. McKenzie AL: Physics of thermal processes in laser-tissue interac-
a majority of the reports are anecdotal. The initial clinical tion, Phys Med Biol 35(9):1175–1209, 1990.
12. Knappe V, Frank F, Rohde E: Principles of lasers and biopho-
results with photoactivated disinfection also show promis-
tonic effects, Photomed Laser Surg 22(5):411–417, 2004.
ing applications for disease control. More information on 13. Springer TA, Welch AJ: Temperature control during tissue weld-
photoactivated disinfection and low-level laser therapy is ing, Appl Optics 32(4):517–525, 1993.
presented in Chapter 15. 14. Bornstein E: Near-infrared dental diode lasers: scientific and photo
The future holds the promise of additional laser applica- biologic principles and applications, Dent Today 23(3):102–104,
tions. Optical coherence tomography using a laser to create 2004. 106–108.
a three-dimensional image will be a tremendous advance for 15. Rechmann P, Goldin DS, Hennig T: Er:YAG lasers in dentistry:
dental diagnosis, and laser Doppler instruments will be able an overview. In Featherstone JD, Rechmann P, Fried DS, editors:
to measure blood flow rates to assess inflammation. Selec- Lasers in dentistry IV, January 25-26, 1998, San Jose, Calif, Proc.
tive ablation of calculus and bacteria and enamel hardening SPIE 3248, Bellingham, Wash, 1998, SPIE—The International
for caries resistance are examples of new procedures under Society for Optical Engineering.
16. White JM, Goodis HE, Kudler JJ, Tran KT: Photo thermal laser
development.36,37 Manufacturers continue to develop tech-
effects on intraoral soft tissue, teeth and bone in vitro. Proceedings
nologies, with clearance for other clinical applications and of the ISLD Third International Congress on Lasers in Dentistry,
laser wavelengths pending. More information on what the Salt Lake City, 1992, University of Utah.
future of lasers in dentistry may hold may be found in 17. Goldman L: Chromophores in tissue for laser medicine and laser
Chapter 17, on laser research. surgery, Lasers Med Sci 5(3):289–292, 1990.
18. Coluzzi DJ: Fundamentals of lasers in dentistry: basic science, tis-
Conclusions sue interaction, and instrumentation, J Laser Dent 16(spec. issue):
4–10, 2008.
The appropriate and effective use of dental lasers in clinical 19. Hale GM, Querry MR: Optical constants of water in the 200-nm
practice requires a firm grasp of their scientific basis and tis- to 200-μm wavelength region, Appl Opt 12(3):555–563, 1973.
sue effects, proper training in techniques and applications, 20. Parker S: Lasers in dentistry, London, 2007, British Dental Asso-
ciation London.
and sufficient operative experience to achieve and maintain
21. Sliney DH, Trokel SL: Medical lasers and their safe use, New York,
proficiency. The clinician can then choose the proper laser(s) 1993, Springer-Verlag.
for the intended application. Although the types of tissue 22. Piccione PJ: Dental laser safety, Dent Clin North Am 48:795–
interaction overlap somewhat, each wavelength has specific 807, 2004.
properties that can be used to accomplish a specific treat- 23. American National Standards Institute: American national stan-
ment objective. Laser energy requires some procedures to be dard for safe use of lasers in health care facilities, Orlando, Florida,
performed much differently from those using conventional 1996, The Laser Institute of America.
instrumentation, but the indications for laser use continue 24. Ando Y, Aoki A, Watanabe H, Ishikawa I: Bactericidal effect of
to expand, with further benefit for patient care. erbium YAG laser on periodontopathic bacteria, Lasers Surg Med
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25. Moritz A, Gutknecht N, Doertbudak O, Goharkhay K, et  al.:
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